Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment.

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

Histologic Comparison of the Fascicular Area of Processed Nerve Allograft Versus Cabled Sural Nerve Autograft.

Background: The use of multiple cables of sural nerve autograft is common for peripheral nerve reconstruction when injured nerve caliber exceeds the nerve graft caliber. Although the optimal matching of neural to nonneural elements and its association with functional outcomes are unknown, it is reasonable to consider maximizing the neural tissue structure available for nerve regeneration. No prior studies have compared directly the cross-sectional fascicular area between cabled nerve autografts and size-selected nerve allografts. This study evaluated the cross-sectional fascicular area between native nerve stumps and two reconstructive nerve grafting methods: cabled sural nerve autograft (CSNA) and processed nerve allograft (PNA). Methods: CSNA from matched cadaveric specimens and PNA were used to reconstruct nerve defects in the median and ulnar nerves of six pairs of cadaveric specimens. Nerve reconstructions were done by fellowship-trained hand surgeons. The total nerve area, fascicular area, and nonfascicular area were measured histologically. Results: The CSNA grafts had significantly less fascicular area than PNA and caliber-matched native nerve. The PNA grafts had a significantly higher percent fascicular area compared with the intercalary CNSA graft. Conclusions: Fascicular area was significantly greater in PNA versus CSNA. The PNA consistently demonstrated a match in fascicular area closer to the native nerve stumps than CSNA, where CSNA had significantly smaller fascicular area compared with native nerve stumps.

Capacity Assessment Tool to Promote Capacity Building in Global Orthopaedic Surgical Outreach.

BACKGROUND: A growing number of nongovernmental organizations from high-income countries aim to provide surgical outreach for patients in low- and middle-income countries in a manner that builds capacity. There remains, however, a paucity of measurable steps to benchmark and evaluate capacity-building efforts. Based on a framework for capacity building, the present study aimed to develop a Capacity Assessment Tool for orthopaedic surgery (CAT-os) that could be utilized to evaluate and promote capacity building. METHODS: To develop the CAT-os tool, we utilized methodological triangulation-an approach that incorporates multiple different types of data. We utilized (1) the results of a systematic review of capacity-building best practices in surgical outreach, (2) the HEALTHQUAL National Organizational Assessment Tool, and (3) 20 semistructured interviews to develop a draft of the CAT-os. We subsequently iteratively used a modified nominal group technique with a consortium of 8 globally experienced surgeons to build consensus, which was followed by validation through member-checking. RESULTS: The CAT-os was developed and validated as a formal instrument with actionable steps in each of 7 domains of capacity building. Each domain includes items that are scaled for scoring. For example, in the domain of partnership, items range from no formalized plans for sustainable, bidirectional relationships (no capacity) to local surgeons and other health-care workers independently participating in annual meetings of surgical professional societies and independently creating partnership with third party organizations (optimal capacity). CONCLUSIONS: The CAT-os details steps to assess capacity of a local facility, guide capacity-improvement efforts during surgical outreach, and measure the impact of capacity-building efforts. Capacity building is a frequently cited and commendable approach to surgical outreach, and this tool provides objective measurement to aid in improving the capacity in low and middle-income countries through surgical outreach.

Proximal Hamate Reconstruction of Proximal Pole Scaphoid Nonunion: A Case Series and Analysis of Clinical Outcomes.

BACKGROUND: Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction. METHODS: A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature. RESULTS: Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified. CONCLUSIONS: Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

Clinical Outcomes of Severely Angulated Fifth Metacarpal Neck Fractures Treated Nonsurgically.

BACKGROUND: Reasonable functional outcomes for nonoperative management of isolated, closed fifth metacarpal neck fractures with up to 70° angulation have been reported; however, reported outcomes for fractures with greater than 70° angulation are limited. This study describes clinical outcomes of nonsurgically treated fifth metacarpal neck fractures with angulation of greater than 70°. METHODS: A retrospective review of patients treated between May 1, 2016, and May 1, 2020, included: (1) patients aged 18 years and above with an isolated, closed, fifth metacarpal neck fracture; (2) nonsurgical treatment; (3) healed fractures with angulation greater than 70° measured on oblique radiographs; and (4) minimum 6-month follow-up after injury. Photographic hand motion and patient-rated outcomes (Functional Hand Scale, Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], 12-item Short-Form Health Survey [SF-12]) were collected and reported. RESULTS: A total of 364 fractures were identified; 11% (40/364) demonstrated angulation of greater than 70° (range: 71°-82°); and 15 patients (inclusion rate: 38%, 15/40) with mean fracture angulation of 73° (range: 71°-77°) participated in the study. Mean follow-up was 32 months (range: 8-120 months), the dominant hand was injured in 87% (13/15) of patients, and 47% (7/15) of patients worked in manual labor. All patients scored the highest rating of "very good" (range: 26-30 of 30 points) on the functional hand scale. A QuickDASH score of zero (no morbidity) was reported in 80% (12/15) of patients. About 87% (13/15) of patients had average or above-average scores on the SF-12 (mean = 109, range: 84-115). CONCLUSIONS: Patients with healed, isolated, closed fifth metacarpal neck malunions with severe angulation greater than 70° demonstrated acceptable functional outcomes based on patient-rated outcomes scoring.

A Framework and Blueprint for Building Capacity in Global Orthopaedic Surgical Outreach.

BACKGROUND: Nongovernmental organizations (NGOs) from high-income countries provide surgical outreach for patients in low and middle-income countries (LMICs); however, these efforts lack a coordinated measurement of their ability to build capacity. While the World Health Organization and others recommend outreach trips that aim to build the capacity of the local health-care system, no guidance exists on how to accomplish this. The objective of this paper is to establish a framework and a blueprint to guide the operations of NGOs that provide outreach to build orthopaedic surgical capacity in LMICs. METHODS: We conducted a qualitative analysis of semistructured interviews with 16 orthopaedic surgeons and administrators located in 7 countries (6 LMICs) on the necessary domains for capacity-building; the analysis was guided by a literature review of capacity-building frameworks. We subsequently conducted a modified nominal group technique with a consortium of 10 U.S.-based surgeons with expertise in global surgical outreach, which was member-checked with 8 new stakeholders from 4 LMICs. RESULTS: A framework with 7 domains for capacity-building in global surgical outreach was identified. The domains included professional development, finance, partnerships, governance, community impact, culture, and coordination. These domains were tiered in a hierarchical system to stratify the level of capacity for each domain. A blueprint was developed to guide the operations of an organization seeking to build capacity. CONCLUSIONS: The developed framework identified 7 domains to address when building capacity during global orthopaedic surgical outreach. The framework and its tiered system can be used to assess capacity and guide capacity-building efforts in LMICs. The developed blueprint can inform the operations of NGOs toward activities that focus on building capacity in order to ensure a measured and sustained impact.

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Anatomical Description and Quantification of Articular Surface Area Visualized in a Cadaveric Model.

PURPOSE: Distal radius (DR) fracture repair using the volar locked plating technique typically involves indirect fracture reduction, assessed using fluoroscopy, without direct visualization of the articular surface. This method of fracture repair may be guided by the rationale that volar radiocarpal ligament disruption may cause radiocarpal instability, although direct articular visualization may facilitate improved fracture reduction. This study investigated anatomical feasibility and articular surface visualization using volar ligament-sparing radiocarpal arthrotomy pertinent to DR fracture repair. METHODS: Ten fresh-frozen cadaveric specimens of the upper extremity underwent volar arthrotomy via the standard flexor carpi radialis approach with partial longitudinal sectioning of the long radiolunate and partial transverse sectioning of the short radiolunate ligaments to visualize the articular surface of the DR. Following arthrotomy, the visible surface of the DR was analyzed using digital photography. The wrist was disarticulated, and the fully exposed articular surface was photographed. The visible area of the articular surface was quantified using digital imaging software by calculating the ratio of the surface area visualized using the arthrotomy to the total articular surface area. RESULTS: The percentage of the articular surface area of the DR visualized using the volar arthrotomy was 76% ± 7.6% (range, 69%-90%), including both the scaphoid facet, lunate facet, and scapholunate ridge. CONCLUSIONS: Volar radiocarpal arthrotomy allows clinically relevant visualization of the articular surface of the DR, including the scaphoid and lunate facets. CLINICAL RELEVANCE: Radiocarpal arthrotomy may facilitate improved articular reduction during DR fracture repair via the volar approach.

Influences of Repair Site Tension and Conduit Splinting on Peripheral Nerve Reconstruction.

BACKGROUND: We investigated the use of a conduit splinting technique to mitigate tension at the coaptation site of a rodent nerve defect model to determine the optimal reconstruction method for segmental nerve defects. METHODS: A rat sciatic nerve segmental defect model was created by excising 5mm of the sciatic nerve unilaterally. Four groups of 10 rats were each reconstructed using 1 of 4 techniques: primary repair, repair with conduit splinting, reverse isograft with conduit splinting, and reverse isograft without splinting. Functional outcomes were assessed at 6 weeks by measurement of Sciatic Functional Index (SFI), and sciatic nerves were harvested at the nonsurvival surgery. Histomorphologic measurements were reported as a value normalized to the average measurements of the control side. The primary outcomes were assessment of nerve continuity and the proportion of nerve fibers in the regenerating nerve compared with the uninjured side. RESULTS: The number of repair site rupture rates was lower when a conduit splint was used-less than half of the primary repairs under tension remained intact at 6 weeks. No difference was seen in axon number, size, and density between primary repairs and those augmented by conduit splints, but worse functional outcomes and more debris were present compared with the intact primary repairs. CONCLUSIONS: Nerve conduit splinting reduced rupture rates, particularly for nerve repairs associated with a segmental defect. No significant difference was seen in the number of axons among techniques. Primary nerve repair under tension that did not rupture demonstrated superior SFI.

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Biomechanical Implications on Wrist Stability in a Cadaveric Model.

PURPOSE: Distal radius (DR) fracture fixation with volar locked plating typically uses indirect fracture reduction without direct visualization of the articular surface in an attempt to preserve the volar radiocarpal ligaments and prevent iatrogenic radiocarpal instability. This study assessed the biomechanical stability after a volar radiocarpal arthrotomy for direct articular visualization for DR fracture repair compared to a standard trans-flexor carpi radialis approach without arthrotomy in a cadaver model. METHODS: Ten fresh-frozen upper extremity matched-pair cadaveric specimens were tested. For each pair, one limb underwent trans-FCR approach with a volar arthrotomy that partially sectioned the long and short radiolunate ligaments to visualize the DR articular surface (Group 1). The contralateral limb underwent standard trans-FCR approach without arthrotomy (Group 2). Following capsular repair (Group 1), all specimens (Groups 1 and 2) underwent biomechanical testing, including axial loading (22.2 N, 44.5 N, 89.0 N, 177.9 N), volar translational, and dorsal translation loading (22.2 N, 44.5 N, 89.0 N) to assess carpal stability using both fluoroscopy and motion capture. Ulnar carpal translation was assessed using the Gilula method, measuring radiographic lunate overhang from the ulnar edge of the lunate fossa relative to the full width of the lunate. Dorsal and volar translation were assessed by measuring lunate overhang with respect to the dorsal or volar radial cortex. To simulate fractures with dorsal radiocarpal ligament disruption, the dorsal capsule was sectioned, and the biomechanical comparisons were repeated. RESULTS: Ulnar translation of the lunate remained below 2 mm for both groups in all testing scenarios. No significant differences were identified in ulnar, volar, or dorsal translation with increasing loads between the groups. CONCLUSIONS: This volar ligament-sparing radiocarpal arthrotomy did not cause biomechanical radiocarpal instability. CLINICAL RELEVANCE: This arthrotomy may provide enhanced visualization of the DR articular surface during fracture fixation without causing iatrogenic wrist instability.

Management of Recalcitrant Cubital Tunnel Syndrome.

Cubital tunnel syndrome is a common upper extremity compressive neuropathy. Recalcitrant cubital tunnel syndrome poses diagnostic and treatment challenges. Potential etiologies of persistent or recurrent symptoms after surgical treatment include an inaccurate preoperative diagnosis, incomplete nerve decompression, iatrogenic injury, postsurgical perineural adhesions, irreversible nerve pathology, or conditions associated with secondary nerve compression. Confirmation of recalcitrant ulnar nerve pathology relies on a thorough history to consider symptoms and chronology, careful examination to quantify nerve function and to assess for focal nerve provocation, and objective testing to highlight a possible nerve lesion such as ultrasonography and electrodiagnostic testing. Conservative treatment may provide symptomatic relief; however, surgical management such as revision neuroplasty, neurolysis, nerve reconstruction, and/or anterior transposition may be indicated. Optimizing the biology of the local nerve environment is critical. No surgical treatment procedure has shown superiority over another; however, individualized treatment is emphasized to improve symptoms and maximize nerve recovery potential.

Histologic and Functional Outcomes of Conduit Wrapping for Peripheral Nerve Repair: Early Results in a Rat Model.

BACKGROUND: The concept of utilizing a nerve conduit for augmentation of a primary nerve repair has been advocated as a method to prevent neural scarring and decrease adhesions. Despite clinical use, little is known about the effects of a nerve conduit wrapped around a primary repair. To better understand this, we investigated the histologic and functional effects of use of a nerve conduit wrapped around a rat sciatic nerve repair without tension. METHODS: Twenty Lewis' rats were divided into two groups of 10 rats each. In each group, unilateral sciatic nerve transection and repair were performed, with the opposite limb utilized as a matched control. In the first group, direct repair alone was performed; in the second group, this repair was augmented with a porcine submucosa conduit wrapped around the repair site. Sciatic functional index (SFI) was measured at 6 weeks with walking track analysis in both groups. Nonsurvival surgeries were then performed in all animals to harvest both the experimental and control nerves to measure histomorphometric parameters of recovery. Histomorphometric parameters assessed included total number of neurons, nerve fiber density, nerve fiber width, G-ratio, and percentage of debris. Unpaired t-test was used to compare outcomes between the two groups. RESULTS: All nerves healed uneventfully but compared with direct repair; conduit usage was associated with greater histologic debris, decreased axonal density, worse G-ratio, and worse SFI. No significant differences were found in total axon count or gastrocnemius weight. CONCLUSION: In the absence of segmental defects, conduit wrapping primary nerve repairs seem to be associated with worse functional and mixed histologic outcomes at 6 weeks, possibly due to debris from conduit resorption. While clinical implications are unclear, more basic science and clinical studies should be performed prior to widespread adoption of this practice.

A Multicenter Matched Cohort Study of Processed Nerve Allograft and Conduit in Digital Nerve Reconstruction.

PURPOSE: Biomaterials used to restore digital nerve continuity after injury associated with a defect may influence ultimate outcomes. An evaluation of matched cohorts undergoing digital nerve gap reconstruction was conducted to compare processed nerve allograft (PNA) and conduits. Based on scientific evidence and historical controls, we hypothesized that outcomes of PNA would be better than for conduit reconstruction. METHODS: We identified matched cohorts based on patient characteristics, medical history, mechanism of injury, and time to repair for digital nerve injuries with gaps up to 25 mm. Data were stratified into 2 gap length groups: short gaps of 14 mm or less and long gaps of 15 to 25 mm. Meaningful sensory recovery was defined as a Medical Research Council scale of S3 or greater. Comparisons of meaningful recovery were made by repair method between and across the gap length groups. RESULTS: Eight institutions contributed matched data sets for 110 subjects with 162 injuries. Outcomes data were available in 113 PNA and 49 conduit repairs. Meaningful recovery was reported in 61% of the conduit group, compared with 88% in the PNA group. In the group with a 14-mm or less gap, conduit and PNA outcomes were 67% and 92% meaningful recovery, respectively. In the 15- to 25-mm gap length group, conduit and PNA outcomes were 45% and 85% meaningful recovery, respectively. There were no reported adverse events in either treatment group. CONCLUSIONS: Outcomes of digital nerve reconstruction in this study using PNA were consistent and significantly better than those of conduits across all groups. As gap lengths increased, the proportion of patients in the conduit group with meaningful recovery decreased. This study supports the use of PNA for nerve gap reconstruction in digital nerve reconstructions up to 25 mm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

Long Segment, Mixed Sensorimotor Nerve Reconstruction with Allograft: A Case Report of High Radial Nerve Injury.

CASE: A 35-year-old man sustained a Grade I open right mid-diaphyseal humerus fracture and high radial nerve transection from a motor vehicle accident. Acute humeral plate osteosynthesis and radial nerve reconstruction using an intercalary 4-cm processed nerve allograft (PNA) was performed. Five years postoperatively, elbow extension, forearm supination, and wrist extension were 5/5 strength and independent digital extension was 5-/5. Radial nerve sensation recovered to 90% of the uninjured side. CONCLUSIONS: Use of PNA resulted in outcomes comparable with or superior to autograft reconstruction or secondary tendon transfers and is a reasonable reconstructive option for similar acute, mixed sensorimotor nerve injuries.

Hand transplantation in the United States: A review of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Database.

Hand transplantation is the most common application of vascularized composite allotransplantation (VCA). Since July 3, 2014, VCAs were added to the definition of organs covered by federal regulation (the Organ Procurement and Transplantation Network (OPTN) Final Rule) and legislation (the National Organ Transplant Act). As such, VCA is subject to requirements including data submission. We performed an analysis of recipients reported to the OPTN to have received hand transplantation between 1999 and 2018. Forty-three patients were identified as having been listed for upper extremity transplantation in the United States. Of these, 22 received transplantation prior to July 3, 2014 and 10 from then to December 31, 2018. Of patients transplanted after 2014, posttransplant functional scores included a decrease in Disabilities of the Arm, Shoulder and Hand questionnaire in 3 of 10 patients, Carroll test scores ranging from 9 to 60 of 99, and monofilament testing with protective sensation achieved in 4 of 6 patients. Complications included rejection in nine recipients with Banff scores from II-IV. One patient experienced graft failure 5 days after transplantation. Of the remaining patients, two were reported as receiving monotherapy and seven receiving dual or triple immunosuppression therapy. The inclusion of VCA in the OPTN Final Rule standardized parameters for safe implementation and data collection.

Guidelines for Short-Term Hand Surgery Outreach Trips: Building Trust and Establishing Continuity.

Global outreach in hand surgery can be exceptionally rewarding for volunteers and their organizations, patients and their communities, and the host medical community. Success can be defined by individual cases that restore function and provide opportunities for a patient and family to contribute to society; however, the broader missions of medical collaboration, education, cultural exchange, and personal growth are critical factors toward building trust and establishing continuity of care for long-term success. Each outreach site and brigade encounters challenges; however, careful planning facilitates optimal conditions and reasonable expectations for enhancing outcomes.

Management of Recalcitrant Carpal Tunnel Syndrome.

Recalcitrant carpal tunnel syndrome presents a clinical challenge. Potential etiologies of persistent or recurrent symptoms after primary carpal tunnel release include incomplete nerve decompression, secondary sites of nerve compression, unrecognized anatomic variations, irreversible nerve pathology associated with chronic compression neuropathy, perineural adhesions, conditions associated with secondary nerve compression, iatrogenic nerve injury, or inaccurate preoperative diagnosis. Understanding the pertinent surgical anatomy and pathophysiology is essential toward developing an effective diagnostic and treatment strategy. A thorough clinical history and examination guide a comprehensive diagnostic evaluation that includes serial examinations, neurophysiologic testing, and imaging studies. Conservative treatment may provide symptomatic relief; however, surgical management involving revision neuroplasty, neurolysis, nerve reconstruction, and/or local soft-tissue flap augmentation may be indicated in refractory cases.

Surgical Technique and Anatomical Considerations for the Modified L'Episcopo Tendon Transfer.

BACKGROUND: Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L'Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction. METHODS: The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed. RESULTS: The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique. CONCLUSIONS: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.